Analyzing Emergency Room Records

A careful analysis of the medical issues in a claim will ultimately save the attorney an
enormous amount of time and money. Decisions regarding the management of the case
will be influenced in part by the types of injuries, the profile of the plaintiff, the
plaintiffs response to treatment, and the ability to refute findings by the physician hired
by the other side. The analysis of medical issues begins with a careful review of the
records generated by the rescue squad and the emergency department. Med Leagues
nurses have reviewed hundreds of cases involving medical records of patients involved
in personal injury cases. We believe that the attorney should never be surprised in the
courtroom or during settlement discussions by potentially negative material in the
plaintiffs medical records. We have found that the pieces of information listed below
are often the crucial keys to a case:

Rescue Squad Records Should be Evaluated to Look for:

1. Injuries at the scene: What did squad members describe as the patients injuries?
Does this match the injuries observed at the hospital?

2. Use of seat belt or broken seat belt: Did the squad members comment on whether
the patient was restrained at the time of the accident? Are there comments
regarding a broken seat belt, indicating that the patient was thrown violently in
the car?
3. Description of car, steering wheel, windshield, seats: A broken steering wheel, a
windshield cracked by a plaintiffs head or broken seats convey the potential for
severe injuries to the plaintiff.
4. Deployment of an airbag: Airbags can cause powder burns to the face and other
acid injuries, traumatic amputation of thumbs, lower head and chest injuries.
5. Plaintiffs activities at the scene: While a plaintiff may not immediately experience
the full effects of his/her injuries, comments such as Patient was observed
walking around at the scene of the accident may imply that the person was not
seriously injured.
6. More than one squad involved in the case: Records may show that a first aid squad
and a mobile intensive care unit were both at the scene of the accident. Be sure
that all the records of both squads are obtained.
7. Behavior of the plaintiff and treatment en route to the ER: What was the plaintiffs
condition during the ambulance trip? What were the medical interventions
provided during the transport? (Administration of oxygen is common.)
8. Documentation that the squad took photos at the scene: Copies of these pictures
should be obtained before this evidence disappears.
Emergency Room Records should be reviewed to determine:
1. Who first saw the patient: Usually a triage nurse will see the patient before the
patient is officially checked in to the ER.

2. How did the patient arrive at the ER: by car or by squad?

3. When did the patient go to the ER in relation to the accident: Was the patient seen
in the ER the same day or was the visit delayed?
4. If the visit did not occur the same day as the accident, is there any reason
indicated for why the patient went to the ER: Does the record say Patient
instructed to go to ER by his attorney?
5. Complaints of the plaintiff: Were these the same complaints that were
documented by the squad?
6. Injuries: If the patient was rear-ended, are low back or cervical spine symptoms
documented? (These symptoms may not occur until 24 hours after the accident.)
Were lacerations severe enough to be sutured? What x-rays were taken and what
did they show?
7. Use of seat belt: Is the patient described as having been restrained at the time of
the accident? (We have seen that this fact is often changed in subsequent records.
At times the unrestrained (at the time of the accident) patient claims to have had
on a seat belt when giving a history of the accident to a treating physician.)
8. Loss of consciousness: Did the patient report a loss of consciousness at the
accident scene?
9. Chronic medical conditions: Look for seizure disorder and transient ischemic
attacks (potential for raising questions of liability), arthritis (pre-existing
condition), deafness (potential for raising questions on liability), hypoglycemia
(drop in blood sugar which may result in lowered attention and may contribute to
causing an accident) and glaucoma or cataracts (decreased vision may contribute
to the accident).

10. Medications taken on a routine basis: Look for sedatives and narcotics, which
may cause drowsiness. Narcotics or other pain relievers raise questions about
pre-existing conditions. Eye drops raise issues concerning visual acuity. A history
of being on antidepressants may be significant if the patient claims to have
become depressed as a result of the accident (as a new condition instead of
acknowledging the existence of a pre-existing condition.)
11. Positive alcohol smell: This may be written as +ETOH or AOB (alcohol on
breath). Some people will misrepresent the amount of alcohol they consumed.
Many will never admit to having had more than 2 beers.
12. Blood alcohol level: Know your states legal definition of intoxication.
13. Drug screen: If the patients blood tested positive for drugs, look at the ER record
to determine if any narcotics were given in the ER. Then check the time on the
blood test to see when the blood was drawn before or after the narcotic was
given.
14. Level of consciousness (LOC): Did the patient report a loss of consciousness?
What was the patients LOC in the ER? A patient described as A&OX3 knew who
he was, where he was and the date. A&Ox4 means all of the above, plus the
patient remembered recent events leading up to the ER visit. This is less
commonly used than A&Ox3.
15. Glasgow Coma Scale: A scale of 15 is the highest possible score. A patient can be
dead and have a score of 3.
16. What did nurses observe about the patient? What symptoms did the patient
experience while in the ER? Was the patients behavior congruent with the
injuries, or did the nurse document symptoms that would cast doubt on the
seriousness of the injuries?

17. Were the appropriate,taken based on the plaintiffs complaints?

18. Were x-rays read by the radiologist or only by the ER doctor initially?: All ER xrays must be over-read by a radiologist later.
19. Did the patient receive discharge instructions? Were they written or oral? Did the
plaintiff sign that instructions were given?
20. Was the plaintiff instructed to seek care from the PMD (Primary Medical
Doctor)? Was this done?
21. Was a prescription given? What type of medication was it?
Careful review of the records created by the rescue squad and emergency department
staff will give you a firm foundation for understanding the injuries the plaintiff
sustained. This information can be used to substantiate or refute later claims of
damages resulting from an accident.